In October, the Pakistan Medical and Dental Council (PMDC) was dissolved by the federal government in a step to regulate the medical profession in the country. In its place, the Pakistan Medical Commission Ordinance 2019 will ostensibly implement a uniform minimum standard of medical education, training and recognition of qualifications in medicine and dentistry in the country. The Pakistan Medical Commission (PMC) will comprise the Medical and Dental Council, the National Medical and Dental Academic Board, and the National Medical Authority.
But weeks after the dissolution of PMDC, the newly formed PMC remains dysfunctional.
The primary function of a regulatory body is to protect its stakeholders, in this case the general public, and undergraduate and postgraduate medical education and training in the interest of the stakeholders. Like the oldest medical regulatory body, the General Medical Council (GMC) in the UK, PMDC was also supposed to discipline those medical practitioners who harm their patients or violate their privacy. GMC enforces strict rules regarding the patient-doctor relationship, for example, and takes strict action against doctors found guilty of misconduct, negligence or abnormal social behaviour.
But over the last many decades — with the exception of a few years — PMDC had been working for the benefit of the owners of private medical colleges and vested interest groups in the public sector. In effect, the institution that should have been safeguarding the interests of the people had instead been working against them. It is very unfortunate that governments too in the past used PMDC for their political benefits and allowed its officials to get involved in all kinds of corruption. It seems PMDC did everything possible to harm and degrade the medical profession to such a degree that doctors lost all respect in society at large. When a regulatory body of a respectable profession behaves not unlike corrupt politicians, crooked businessmen and habitual criminals, then the destruction of the profession and loss of dignity of professionals is inevitable.
The new presidential ordinance for regulating the medical profession fails to address fundamental issues about it in the country
Understanding the disease
There are more than 150 medical colleges and dental schools in Pakistan. The country produces more than 12,800 doctors and 2,100 dental surgeons every year. Most of these doctors and dental surgeons are not well-educated or well-trained. A majority of medical and dental institutes are part-time educational centres, hiring part-time faculty. As a result of such half-hearted efforts, the system produces half-baked, glorified MBBS quacks who cannot compete with reputable world-class doctors.
A regulatory body concerned with the health of people should be able to design a syllabus, curriculum and training system as per the need of various communities facing challenges of health which are unique in nature, and not comparable to any other in the country, or even the world for that matter.
In Pakistan, our disease pattern is different, and our cultural and social behaviour demands a different kind of attention. A majority of our population lives in unhealthy and toxic environments as the rural areas and massive city slums are without clean water or sewerage systems. Half of the population lives below the poverty line, earning less than two dollars a day. With no access to emergency medical and obstetrical care, they do not receive routine vaccination against diseases such as diphtheria, polio, typhoid or other preventable infectious diseases.
Our medical students and doctors have no exposure to this population and their diseases, nor does their curriculum address medical issues related to them. In the past, no regulatory body even bothered to bring about significant changes in the curriculum of medical schools in order to enable our medical students to understand their own people and their misery.
Our doctors lack communication skills and are not aware of ethical practices or patients’ rights. A few years ago, when doctors went on strike in Lahore, a young doctor in a children’s ward removed the intravenous line of a patient at the start of the strike to express his anger against the government!
In the last many years, PMDC failed to ever address these essential aspects of medical practice because of wrong priorities and massive corruption by top officials in PMDC, working in the interest of the owners of private medical colleges and vested interest groups in public medical schools.
PMDC showed no spine in facing the provincial government and take measures to stop the mushroom growth of medical universities and colleges. Instead, it facilitated the corrupt demands of government officials and even allowed one vice chancellor to open a night medical college.
The previous medical councils allowed professional businessmen and crooked medical professionals to open medical schools without affiliated hospitals, gave them permission to increase seats without minimal required faculty members and were unable to stop them charging exorbitant tuition fees and donations for admission with or without merit.
They failed to stop the massive increase in self-financed medical seats in public medical colleges. They encouraged the business of medical education in private and public medical colleges at the cost of patients’ lives and human misery.
PMDC showed the least interest in improving the poor performance of medical trainees and their supervisors in the so-called teaching hospitals. They showed no intention of auditing the high failure rate of fellowship and membership candidates appearing in the College of Physicians and Surgeons Pakistan (CPSP) examinations. They failed to introduce improvements to the current postgraduate training system which could better guide students and help produce competent, skilled and ethical specialists.
Under the watch of PMDC, medical universities started different postgraduate specialist training programmes, comprising the same deficient part-time faculty, uninterested in teaching. With the exception of very few medical institutes, we do not have structured postgraduate training programmes in the various fields of medicine as per international standard practice.
The trainees perform their duties without supervision, causing mortality and morbidity. Neither they nor their trainers are accountable to anyone about the increasing number of mishaps across the country.
Facing such a miserable state of affairs, one hoped that, in the presence of a senior dental surgeon as president of the country, a new presidential ordinance about medical education and training will try to urgently address the above-mentioned serious issues related to public health, life and death. Unfortunately, the last two attempts of the present government to improve the situation have not been well thought out. They failed to address these problems objectively.
The new presidential ordinance to form PMC with three different departments offers some good ideas and guidelines to conduct itself as a regulatory body. But it has failed to address a fundamental question about the medical profession: What kind of doctors does Pakistan need and how will they be trained to treat patients?
Will we continue to produce doctors for overseas countries? Is it acceptable to produce doctors who have no clue about the ground realities of our sick population and no intention to serve them? Will we allow the owners of private medical colleges and universities to make billions of rupees in the name of education? Will PMC have any say in matters of public sector medical and dental colleges and medical universities? Will PMC have enough power to audit the conduct of CPSP and postgraduate training in universities?
The present commission has some eminent names on the council whose integrity is unquestionable, but the government has not been transparent in forming the commission. The government is not supposed to abolish an institute by one simple order and sack the workers at whim. It should, instead, introduce reform with the consensus, of everyone for the benefit of the main stakeholder. Bulldozing an ordinance which directly allows private medical colleges to make as much money as possible is not correct. Announcing an exit exam to be conducted by PMC after five years in all medical colleges will not prevent ill-trained persons becoming doctors. It will simply convert medical schools to tuition centres for students and the system will not be beneficial to patients.
The above-mentioned are just a few points that highlight that the ordinance is not well thought out and will not be acceptable despite some good initiatives. The government should restore PMDC with reforms to make it a democratic, independent and powerful body that can produce professional doctors who can work for the country.
In 1906, the US government appointed Abraham Flexner, a non-doctor, to look into the matters of 129 medical colleges in the country. After Flexner’s report, US politicians closed 107 of the colleges, with consensus, in the interest of the general public. From that day onward, medical education and medical services in the US had a direction and, after 100 years, US citizens enjoy higher quality medical care.
Sadly, we lack such visionary politicians.
The writer is former secretary general of Pakistan Medical Association
Published in Dawn, EOS, December 8th, 2019